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Two Person IV Medication Administration

nurses working with patient
Background:

This project aimed to evaluate the safety, efficiency and cost of a two person independent IV medication administration procedure to the bedside compared to current single person IV medication administration. A secondary objective was to capture the frequency of interruptions during the IV medication process.

Methods:
A randomised controlled design using direct observations at pre and posttest was undertaken to capture IV medication administration data on four clinical areas at a major public tertiary teaching hospital. Medication safety culture was also assessed along with the time taken to administer an IV medication and the frequency of interruptions during this process.

Results:
A total of 310 IV medications were observed being prepared and administered with a total of eight errors (3%) identified across both the intervention and controlled wards. Across both the intervention and controlled wards there were low numbers of IV medication errors observed which were further corroborated by low numbers of IV medication clinical incidents reported. Findings revealed that there was no conclusive evidence that using a two person IV administrative check to the bedside was any safer than using a single nurse administration.

Fifty four percent (n=167) of IV medication administrations were interrupted between 1 and five times, with a total of 305 interruptions observed. The top reasons for interruptions included; to discuss a patient (n=76; 26%) followed by a request from a patient or relative (n=46; 15.8%). Mean medication safety culture scores were positive indicating that staff regard medication safety as important. Timing of IV medication preparation and administration were collected with a mean time of 11 minutes required to prepare, check and administer IV medications in this sample of patients. To contextualised this finding, for every 100 IV medications administered the extra five minutes required to have a second nurse check the IV medication to the bedside equates to an additional 8 hours and 20 minutes of nursing time required.

Conclusion:
The safety net of double checking IV medications remains questionable with definitive findings as to the benefits of this procedure not able to be verified by this project. The reinforcement of independent rather than collaborative medication checking is warranted to ensure that medication checks are completely impartial to outside influences. Finally, any interruption during medication preparation and administration should be viewed as detrimental to patient safety. As such staff and patients need to be made aware of the fact that interruptions can lead to medication errors.

 

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Implementation of Visual Risk Alerts at Royal Perth Hospital (RPH).

RPH recognised that there were significant gaps in how the risk of patient aggression was communicated to staff, in particular those with limited or no access to patient documentation, electronic patient information systems or verbal handover.

The RPH Aggression Prevention and Intervention and Research portfolios undertook a study into systems that alert staff to the risk of patient aggression.  This study was supported by grants from the RPH ‘Foundation for Nursing Research’ and ‘Nursing Fellowship’.

One of the recommendations from the study was to introduce signage that would visually alert both clinical and non-clinical staff to the risk of aggression.

This has now been introduced, supported by a Standard Operating Procedure and Education

A recent survey has been undertaken to audit the visual alerts against the SOP and a further survey is planned to assess the effect of the alerts on the original identified staff groups.

In the interim, the feedback from staff has been very positive in enabling them to identify risk, ask for a verbal handover of the behaviour of concern and any triggers / relievers and precautions required.

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Amazing Nursing and Midwifery Care Project

Amazing Nursing and Midwifery Care Group

Amazing Nursing and Midwifery Care Project Update July 2019

The Amazing Nursing and Midwifery Care (ANMC) initiative has been successfully rolled out to 22 clinical areas across the Royal Perth Bentley Group (RPBG).  Highlighted baseline findings revealed that:

  • Patient allocation model of care was reported to be the most frequently used model within the organisation.
  • The Nursing Team Work Survey reported that only 50-75% of the time nurses felt that they experienced ‘trust’, ‘team orientation’, ‘backup’, ‘team leadership’ that their colleagues had a full understanding their roles and responsibilities when working in a team.
  • The majority (81.8%) of nurses stated that safety shift huddles made them more informed about risks in their area
  • Yet when asked if the huddle improved patient safety, 51% of nurses responded that they either didn’t agree or were unsure.
  • Patients were asked also to rate their inpatient experience with the majority of findings showing that:
      • Their views and concerns were always listened to.
      • Their needs were always met.
      • They always felt cared for.
      • They were involved in decisions about their care.
      • They were always kept informed.
  • The bedside handover evaluation is in progress and the no pass call bell strategy has also been implemented.

These baseline findings do highlight the need for techniques to improve staff/patient communication, collaboration and responsiveness. It is anticipated that the ANMC strategies will significantly improve patient care by utilising a more holistic approach with patients and their families which is underpinned by a strong, safe and efficient team culture.

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Flagging Systems

Update! Alert Systems in use at Royal Perth Hospital (RPH) for Patient Aggression, How they Affect Identified High Risk Staff Groups and Alert Systems in Similar Hospitals. 

RPH has a significant organisational and occupational safety and health risk relating to patient aggression.  It was recognised that there were significant gaps in how this risk was communicated to staff, in particular those with limited or no access to patient documentation, electronic patient information systems or verbal handover.

The RPH Aggression Prevention and Intervention and Research portfolios undertook a study into systems that alert staff to the risk of patient aggression.  This study was supported by grants from the RPH ‘Foundation for Nursing Research’ and ‘Nursing Fellowship’.  Key objectives were to identify alert systems in place within RPH, assess their effect on identified high risk staff groups, review current literature and explore alert systems used in similar hospitals.

The study demonstrated an unambiguous evidence base supporting aggression risk alert systems and the governance required to support these.   Recommendations were made to increase the opportunities to communicate/alert staff to the risk of patient aggression through clinical documentation, referral systems, electronic patient information systems and the use of visual risk alerts.  The key priority was to develop the governance around the use of alert systems prior to their introduction to ensure the aggression risk alert process was fair and lawful, objective, based on a specific incident(s) and risk assessment and that there was clearly defined criteria, authorisation and review process.  The governance process also needed to explore the issues around open disclosure, informing and when not to inform patients that they have an alert specific to aggression.

The recommendations from the study had the potential to alert every RPH staff group of potential risk, facilitating their ability to implement risk reduction measures, potentially preventing or reducing the consequence of patient initiated aggression.

Significant progress has been made in the two years following the report and recommendations.  Most notable is the introduction of signage designed to visually alert staff to the risk of patient aggression.  These alerts are yellow and black magnets on the patient journey board and yellow and black signs on the entrance to single patient rooms or above the patient’s bed space within shared rooms.  The governance around the use of the visual alerts is underpinned by a standard operation procedure which includes criteria for use, authorisation, review, open disclosure and safe systems of work and is supported by education.

A recent survey has been undertaken to audit the visual alerts against the SOP and a further survey is planned to assess the effect of the alerts on the original identified staff groups.  Anecdotally, feedback from clinical and non-clinical staff indicates that the visual alerts assist them in identifying risk and offers opportunity to seek a verbal handover as to the risk behaviours, triggers, relievers and required precautions.  One other notable improvement in regards to the visual alerts is that any patient with a visual alert must have a nurse escort during any inter hospital transfer, again improving the opportunity for verbal handover of risk.

In regards to clinical documentation, communicating the risk of aggression has improved with the review of the ED Triage form to include a section relating to behaviour in the ward handover section of the form.

In regards to electronic patient information systems, there have been some improvements with select ward staff gaining access to the Emergency Department (EDIS) and Mental Health (PSOLIS) risk alerts and ward staff having access to iSOFT handover on patients who are behavioural ‘patient of concern”.  A whole of WA Health electronic system is being progressed at a WA Health level following the Health Ministers Summit on Violence.  It is anticipated that this will also support the outpatient areas who continue to have very limited communication in regards to aggression.

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Hospital Discharge Stage 2

Improving the hospital discharge process to minimize patient readmission: a partnership with consumers.

This proposal is based upon findings of pilot work for improving patient discharge processes undertaken in 2017 in the Acute Medical Unit1.

The 50 observed discharges recorded waiting times of 209 mins (median) due to delays in paperwork/prescriptions, availability of medical staff or competing service delivery demands. Of the 43 patients followed up at 1 week, 7 (16%) had been readmitted. Patients reported lack of clarity about their hospitalisation, expectations for self-care, and frustration with delays. Nurses reported being uncertain if patients understood discharge information/expectations, and that constant, competing demands led to rushed discharge conversations.

The aim of this research is to refine and trial innovative processes to prepare patients for discharge including a focused final conversation to ensure understanding and clarity for self-management at home.

This has been shown to improve self-management and decrease readmissions.
This will be achieved through –

• Enabling in-patients, with family, to formulate ‘questions for my team’ about current treatments and expectations upon discharge.

• Incorporating strategies such as ‘teach-back’ to gauge patients’ understanding of self-management requirements; simplify information exchange by creating ‘5 most important points’ to guide discussions

• Assessing new interventions using 50 observed patient discharges

• Following-up patients at 1 and 6 weeks to determine readmission/satisfaction/coping

• Using Focus groups/short surveys of health professionals and patients to determine impact/effectiveness of interventions

• Ensuring health literacy and patient centredness are central to methodology

1. Foundation for Nursing Research 2017– Hahn, Kelly, Leslie & Brearley.